A 46-year-old man comes to the office for a routine health maintenance examination. He feels well and has no ongoing complaints. His past medical history is significant for generalized anxiety disorder, for which he takes sertraline. Over the past year, he has had 3 female sexual partners and does not regularly use condoms. He drinks 1 or 2 cocktails after work most nights but does not use tobacco or illicit drugs. Vital signs are normal. Laboratory evaluation reveals a positive HIV test. Subsequent laboratory results are as follows: Which of the following is indicated for this patient?

Question

A 46-year-old man comes to the office for a routine health maintenance examination. He feels well and has no ongoing complaints. His past medical history is significant for generalized anxiety disorder, for which he takes sertraline. Over the past year, he has had 3 female sexual partners and does not regularly use condoms. He drinks 1 or 2 cocktails after work most nights but does not use tobacco or illicit drugs. Vital signs are normal. Laboratory evaluation reveals a positive HIV test. Subsequent laboratory results are as follows:

Which of the following is indicated for this patient?

Quizplus · Accepted Answer

Explanation: Antiretroviral therapy (ART) is generally indicated for all patients with HIV regardless of CD4 count. In the past, ART initiation was often postponed for patients with early HIV (eg, CD4 >500/mm³) due to the toxicity of long-term treatment and the lower risk of HIV-related complications early in the disease course. However, current ART medications are well tolerated, and early ART initiation is associated with significant reductions in long-term HIV-related complications, including: ³ Immunosuppression: Patients who start ART with low CD4 counts (eg, <200/mm³) often cannot fully reconstitute CD4 levels to >500/mm³. However, those who initiate ART at higher CD4 counts often restore CD4 counts to normal. Inflammatory diseases: HIV causes significant immune stimulation and leads to chronically high levels of proinflammatory cytokines. This drives several of the long-term complications of HIV infection, including cardiovascular disease, renal disease (eg, HIV-associated nephropathy), liver disease, neurologic disease (eg, HIV-associated neurologic disease), and malignancy. Early ART initiation reduces the amount of time that patients are exposed to proinflammatory cytokines and, therefore, reduces risk for inflammatory complications. Oncogenic viral reactivation: ART reconstitutes cell-mediated immunity, which lowers the risk of oncogenic viral reactivation (eg, HHV-8, HPV, EBV) and the subsequent development of AIDS-defining malignancies (eg, Kaposi sarcoma, invasive cervical cancer, lymphoma). Early ART initiation also dramatically reduces the risk of HIV transmission to others. Patients with fully suppressed viral loads are considered noninfectious and cannot transmit the virus to sexual partners. Patients with a new diagnosis of HIV undergo testing for exposure or immunity to several pathogens, including hepatitis viruses A, B, and C; varicella-zoster virus; cytomegalovirus; and Toxoplasma. Those who have no immunity to hepatitis A or B require vaccination. This patient has immunity to hepatitis A (positive IgG) and has evidence of previous vaccination for hepatitis B (positive surface antibody with negative surface antigen and core antibody). Although his serology is positive for Toxoplasma and cytomegalovirus (CMV), primary prophylaxis against Toxoplasma (eg, trimethoprim-sulfamethoxazole) is indicated only for those with CD4 counts <100/mm³. Primary prophylaxis against CMV (eg, ganciclovir) is not indicated in patients with HIV, regardless of CD4 count, but is used in some organ transplantation recipients (CMV-seropositive recipients). Educational objective: Patients with HIV should be started on antiretroviral therapy regardless of CD4 count to reduce HIV-related morbidity and death.

A 46-Year-Old Man Comes to the Office for a Routine